The successful management of Thirty-six hepatopancreatobiliary surgeries under the intensive protective arrangements during the COVID-19 pandemic.

ackground: During the pandemic of COVID-19, the overwhelm of infected patients created an exponential surge for ICU and ward beds. As a result, a major proportion of elective surgeries was postponed. However, various emergency and urgent procedures were allowed. Due to the mortality complications of hepatopancreatobiliary issues, we decided to afford urgent procedures under intensive protective arrangements. Method and results: In our ward (liver transplant), 4 ICU beds and 16 ward beds were allocated to non-COVID-19 patients. A total of 36 hepatopancreatobiliary procedures were managed for one month. All the surgeries were afforded under personal protective equipment and other intensive protective arrangements for personnel and patients. During 6 weeks following the surgery, all patients were followed up through telemedicine and no new case of COVID-19 was detected. Conclusion: In general, it appears that intensive protections could significantly reduce the number of COVID-19 incidence among patients with co-morbidities who undergo invasive procedures.

Distinct Clinical and Genetic Findings in Iranian Patients With Glycogen Storage Disease Type 3.

OBJECTIVES: Glycogen storage disease type 3 (GSD-III) is a rare inherited metabolic disorder caused by glycogen debranching enzyme deficiency. Various pathogenic mutations of the AGL gene lead to abnormal accumulation of glycogen in liver, skeletal, and cardiac muscles. Here, we report distinct clinical and genetic data of Iranian patients with GSD-III. METHODS: Clinical and laboratory data of 5 patients with GSD-III were recorded. Genetic investigation was performed to identify the causative mutations. RESULTS: Three patients had typical liver involvement in childhood and one was diagnosed 2 years after liver transplantation for cirrhosis of unknown etiology. Four patients had vacuolar myopathy with glycogen excess in muscle biopsy. All patients had novel homozygous mutations of the AGL gene namely c.378T>A, c.3295T>C, c.3777G>A, c.2002-2A>G, and c.1183C>T. CONCLUSIONS: This is the first comprehensive report of patients with GSD-III in Iran with 2 uncommon clinical presentations and 5 novel mutations in the AGL gene.

Potential therapeutic applications for Terminalia chebula in Iranian traditional medicine.

Terminalia chebula (family: Combretaceae) is widely used in the traditional medicine of India and Iran to treat diseases that include dementia, constipation, and diabetes. This tree is known in Iranian traditional medicine (ITM) as halileh or halilaj and the fruit is used to develop treatments. It is described in ITM as an astringent that has a "cold" and "dry" temperament. References to the medicinal properties of Terminalia chebula were collected from important ITM sources and from modern medical databases (PubMed, Scirus, ScienceDirect, and Scopus). The medicinal properties described for this tree in ITM were compared with those reported in studies of modern phytotherapy. The results confirm that the tree referred to as halileh in traditional books is the Terminalia chebula used in present-day studies. Treatments that have not been evaluated in modern phytotherapy but have been traditionally treated with Terminalia chebula include fever, and psychological and psychiatric issues. This article confirms the medicinal uses of Terminalia chebula.

Diffusion-weighted magnetic resonance imaging for diagnosis of liver fibrosis and inflammation in chronic viral hepatitis: the performance of low or high B values and small or large regions of interest.

OBJECTIVE: To investigate the performance of different b values and regions of interest (ROI) for diagnosing liver fibrosis in patients with chronic viral hepatitis by using diffusion-weighted (DW) magnetic resonance imaging (MRI). METHODS: Eleven healthy participants and 33 patients with viral hepatitis B or C were enrolled. The stage of liver fibrosis and the grade of necroinflammation were determined by using a histologic activity index. Single-shot spin-echo echo-planar DW-MRI was performed in all participants at b values of 0-500, 0-700, and 0-1000 s/mm(2) by using 2 circular small and large ROIs of 100 and 200 mm(2). To evaluate the performance of different b values for determining cirrhosis, the receiver-operating characteristic curves were depicted, and the areas under the curves were compared. RESULTS: The average values of apparent diffusion coefficients significantly decreased with increasing stage or grade categories at all the 3 b values and for both small and large ROIs. The performance at b = 500 s/mm(2) was significantly better than b = 1000 s/mm(2) for determining cirrhosis or bridging fibrosis. The cut point of 153.4 for apparent diffusion coefficient (×10(-5) mm(2)/s) at b = 500 s/mm(2) could determine cirrhosis or bridging fibrosis with a sensitivity of 96% and specificity of 82%. No difference was found between the average apparent diffusion coefficient values of large or small ROIs. Also, there was no difference in performance of large or small ROIs in the diagnosis of liver fibrosis. CONCLUSIONS: This study provided beneficial data for clinical utilisation of DW-MRI in diagnosing liver fibrosis: b = 500 s/mm(2) is better in performance than b = 1000 s/mm(2), and a small ROI of 100 mm(2) is sufficient for determining cirrhosis or bridging fibrosis.

Imaging and Imaging-Guided Interventions in the Diagnosis and Management of Hepatocellular Carcinoma (HCC)-Review of Evidence.

The imaging of hepatocellular carcinoma (HCC) is challenging and plays a crucial role in the diagnosis and staging of the disease. A variety of imaging modalities, such as ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) and nuclear medicine are currently used in evaluating patients with HCC. Although the best option for the treatment of these cases is hepatic resection or transplantation, only 20% of HCCs are surgically treatable. In those patients who are not eligible for surgical treatment, interventional therapies such as transcatheter arterial chemoembolization (TACE), percutaneous ethanol injection (PEI), radio-frequency ablation (RFA), percutaneous microwave coagulation therapy (PMC), laser ablation or cryoablation, and acetic acid injection are indicated. In this paper, we aimed to review the evidence regarding imaging modalities and therapeutic interventions of HCC.

Safety and efficacy of locally manufactured pegylated interferon in hepatitis C patients.

BACKGROUND: To evaluate the safety and effectiveness of locally produced pegylated interferon-alpha2a in treatment-naïve patients with chronic hepatitis C. METHODS: All treatment-naïve patients diagnosed with chronic hepatitis C who referred to two university based outpatient clinics in Tehran from December 2007 to May 2008 were enrolled. Exclusion criteria included the presence of a debilitating disease, decompensated cirrhosis, or refusal to participate in the study. Patients were treated with 180 microg pegylated interferon-alpha2a (Pegaferon) weekly and 800 - 1200 mg ribavirin daily for 24 or 48 weeks depending on genotype and weight. Viral and biochemical response and adverse drug reactions were recorded. RESULTS: A total of 108 patients were enrolled; 63 with genotype 1 and 45 with genotypes 2 and 3. The mean age of the patients was 39 years (range: 19 - 65). Ninety-seven patients completed the study and 76 achieved sustained viral response. The sustained viral response among patients completing the study was 67% for genotype 1 and 95% for genotypes 2 and 3. Adverse events were well tolerated and none led to discontinuation of treatment, however dose adjustment was necessitated in 16 patients. The most common adverse events were fatigue (73.5%), poor appetite (66.2%), and feverishness (57.4%). The mean hemoglobin drop was 2.9 g/dL. CONCLUSION: Locally produced PEG-IFN in Iran is safe and effective in treatment-naïve chronic hepatitis C.

Result variation and efficiency kinetics in real-time PCR.

Fluorescent monitoring of DNA amplification is the basis of real-time PCR. Absolute quantification can be achieved using a standard curve method. The standard curve is constructed by amplifying known amounts of standards under identical conditions to that of the samples.The objective of the current study is to propose a mathematical model to assess the acceptability of PCR results. Four commercial standards for HCV-RNA (hepatitis C virus RNA) along with 6 patient samples were measured by real-time PCR, using two different RT-PCR reagents. The standard deviation of regression (Sy,x) was calculated for each group of standard and compared by F-Test. The efficiency kinetics was computed by logistic regression, c2 goodness of fit test was preformed to assess the appropriateness of the efficiency curves.Calculated efficiencies were not significantly different from the value predicted by logistic regression model. Reactions with more variation showed less stable efficiency curves, with wider range of amplification efficiencies.Amplification efficiency kinetics can be computed by fitting a logistic regression curve to the gathered fluorescent data of each reaction. This model can be employed to assess the acceptability of PCR results calculated by standard curve method.

Immunogenicity of recombinant hepatitis B virus vaccine in patients with and without chronic hepatitis C virus infection: a case-control study.

AIM: To compare the response of standard hepatitis B virus (HBV) vaccination between patients with chronic hepatitis C virus (HCV) infection and healthy individuals. METHODS: This is a prospective case-control study. A total of 38 patients with chronic HCV infection and 40 healthy controls were included. Vaccination was performed by injection of 20 microg recombinant HBsAg into the deltoid muscle at mo 0, 1 and 6. Anti-HBs concentration was determined 3 mo after the last dose and compared between the two groups. The response pattern was characterized as (1) high-response when the anti-HBs antibody titer was > 100 IU/L, (2) low-response when the titer was 10-100 IU/L and (3) no-response when the titer was < 10 IU/L. RESULTS: In the patient group, there were 10/38 (26.3%) non-responders, 8/38 (21.1%) low-responders and 20/38 (52.6%) high-responders. The corresponding values in the control group were 2/40 (5.0%), 7/40 (17.5%) and 31/40 (77.5%), respectively. The response pattern was statistically different between the two groups. In multivariate analysis, smoking was a significant confounder, while HCV infection lost its significant correlation with lower antibody response. CONCLUSION: Patients with chronic HCV infection tend to respond weakly to HBV vaccination compared to healthy individuals, though this correlation is not independent according to multivariate analysis.

Immunogenicity of hepatitis B vaccine in multi-transfused thalassemic patients with and without hepatitis C infection: a comparative study with healthy controls.

BACKGROUND: Hepatitis C virus (HCV) infection is highly prevalent in thalassemic patients. This may decrease serum antibody response to hepatitis B virus (HBV) vaccine. There is also some alteration in the immune system of multi-transfused thalassemic patients as a consequence of iron overload. We deduced that HCV infection may reduce the effectiveness of HBV vaccine in multi-transfused thalassemic patients. MATERIAL/METHODS: Subjects were cited and studied prospectively in three groups. Group 1:125 multi-transfused thalassemic patients with negative serum HCV antibody, Group 2:96 multi-transfused thalassemic patients with positive serum HCV antibody on at least 2 different occasions, and Group3:100 healthy subjects. Subjects in all groups had negative serum HBsAg, anti-HBc, and anti-HBs, and they received three 20-microg doses of recombinant HBV vaccine in months 0,1, and 6. The anti-HBs titer was obtained one month after the last dose of vaccine and was considered seroprotective if > or =10 IU/l. RESULTS: The seroprotection rate was 83.2% in Group 1 and 80.2% in Group 2 (P = 0.74). It was 86% in healthy subjects, which didn't significantly differ from HCV-positive and -negative thalassemics (P = 0.56). Moreover, the mean values of ALT among the responder and non-responder thalassemic patients were 55.5 +/- 41.9 and 57.4 +/- 48.5 U/l, respectively (p = 0.802). During the vaccination periods, patients in all 3 groups did not show any significant adverse reactions. CONCLUSIONS: Our study shows that three standard doses of HBV vaccine are immunogenic and safe in multi-transfused thalassemic patients with or without HCV infection.